Provider Demographics
NPI:1801838321
Name:EVANSVILLE PEDIATRIC DENTISTRY, P.C.
Entity Type:Organization
Organization Name:EVANSVILLE PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-479-8609
Mailing Address - Street 1:7200 E VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4068
Mailing Address - Country:US
Mailing Address - Phone:812-479-8609
Mailing Address - Fax:812-479-5554
Practice Address - Street 1:7200 E VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4068
Practice Address - Country:US
Practice Address - Phone:812-479-8609
Practice Address - Fax:812-479-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010159A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty